Form 63-22 - Premium Excise Return For Domestic Insurance Companies

Part I. Premium Excise

11 Total of all net direct premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 1

12 Net direct premiums for insurance of property or interests in other states or countries where a

tax is actually paid by said company or its agents (Supporting schedule is required showing by states . . . . . . . . . . . . . . . . ❿ 2

the total business written. Copy of Schedule T is accepted, if admitted states are designated.)

b. States or

countries in which

Total

Massachusetts

company pays no tax

add a + b

13 Total net direct premiums subject to tax. Subtract line 2 from line 1 . . . . . . 3 ❿ $

❿ $

14 Premiums returned or credited to policyholders as dividends

(unabsorbed premium deposits) on direct premiums . . . . . . . . . . . . . . . . . 4 ❿

15 Taxable premiums. Subtract line 4 from line 3. Enter the result in

line 1 in Computation of Excise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 $

16 Are net direct premiums so reported in lines 1 and 3 of Part I?

Yes

No.

17 Have all dividends claimed as a deduction in line 4 of Part I been included as taxable premiums on this return or on a previous Massachusetts return?

Yes

No.

18 If the answer to line 6 or line 7 is “No,” please explain ________________________________________________________________________________

Part II. Gross Investment Income

From NAIC Annual Statement, Form 2, Underwriting and Investment Exhibit, Part I, Column 8, or Form 9, Operations and Investment Exhibit, Part I, Column 8,

for the taxable year.

11 Interest on bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12 Dividends on preferred stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

13 Dividends on common stocks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Interest on mortgage loans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15 Real estate income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Interest on collateral loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17 Cash on deposit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

18 Other invested assets

a___________________________________________________________________ 8a

b___________________________________________________________________ 8b

c___________________________________________________________________ 8c

d___________________________________________________________________ 8d

e___________________________________________________________________ 8e

19 Total invested assets. Add lines 8a through 8e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Gross investment income. Add lines 1 through 9. Enter the result in line 2 in Computation of Excise. . . . . . . . . . . . . . . . . . . . 10